Acute occlusion of an abdominal aortic aneurysm--case report and review of the literature

A poor outcome in non-occlusive thrombo-embolic limb ischaemia related to the dislocation of mural thrombus from an abdominal aortic aneurysm

Background

Acute thrombosis of an abdominal aortic aneurysm with acute limb ischaemia is an unusual complication and is associated with high mortality. Dislocation of the intrasaccular mural thrombus could be one of the mechanisms. For the most part, acute limb ischaemia presents with absent pulses, compatible with the clinical findings, which include pain, paraesthesia, and paralysis. Herein, we report a rare condition with detectable distal pulses in advanced limb ischaemia due to poor perfusion caused by the dislocation of mural thrombus from an abdominal aortic aneurysm.

Case presentation

A 74-year-old male patient with underlying hypertension and chronic renal disease presented at the emergency room with bilateral lower limb paralysis after falling on his back in the bathroom an hour prior. He reported numbness and weakness of his lower limbs, which was gradually worsening, over the past week. Physical examination showed cyanotic mottling of the lower limbs with paralysis. However, the dorsalis pedis pulse was intact. Computed tomography angiography showed a 7.3 cm abdominal aortic aneurysm containing highly irregular mural thrombus in the early phase, with slow perfusion of the contrast medium in the arteries below the bifurcation during the delayed phase. After traumatic spinal injury was excluded, an emergent endovascular aneurysm repair was performed. Although vital signs were initially stable post-surgery, both lower limbs were still paralysed and did not improve. He then experienced reperfusion injury with metabolic acidosis. There was no urine output despite intravenous hydration. Laboratory data included potassium 7.7 mEq/L, lactate 110 mg/dL, white blood cells 23,700/uL, and myoglobin 46,590 ng/mL. Even under critical medical care and continuous venovenous hemofiltration, his hemodynamic status worsened. He developed hypotension and needed endotracheal intubation because of loss of consciousness and respiratory failure. The patient finally died due to ventricular tachycardia even after several rounds of cardiopulmonary resuscitation with cardioversion.

Conclusion

The unusual clinical presentation of detectable lower limb pulses in advanced limb ischaemia showed that poor blood perfusion related to dislocation of mural thrombus in abdominal aortic aneurysm might mislead clinicians and delay accurate diagnosis and treatment.

Acute Thromboembolism from Trauma in a Patient with Abdominal Aortic Aneurysm

Case Presentation

A 64-year-old man with a history of a 5.5-centimeter (cm) abdominal aortic aneurysm (AAA) presented to the emergency department (ED) complaining of severe back pain after climbing over a fence and falling a distance of eight feet. Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity. The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally as well as absent posterior tibialis pulses bilaterally and cold, insensate lower extremities. Point-of-care ultrasound identified an approximate 7-cm infrarenal AAA with a mural thrombus present. After receiving several computed tomography (CT) studies including CT head without contrast and CT angiography of the chest, abdomen and pelvis, the patient was diagnosed with acute thrombosis of AAA and associated thromboembolic occlusion of both his right and left distal iliac vessels causing bilateral acute limb ischemia. He immediately received unfractionated heparin and was admitted to the hospital for embolectomy and intra-arterial tissue plasminogen activator.

Discussion

Acute thrombosis of AAA and subsequent thromboembolic events are a rare but significant complication that can occur in patients with a history of AAA. Thromboembolic events may occur spontaneously or in the setting of blunt abdominal trauma. Common presenting signs and symptoms include distal limb ischemia and absent femoral pulses. Timely management and recognition of this rare complication is vital as this condition can ultimately result in limb loss or death if not treated in a timely manner. Heparinization after confirmation of non-ruptured AAA as well as vascular surgery, and therapeutic and vascular interventional radiology consultations are key steps that should be taken to decrease patient morbidity and mortality.

An Unusual Case of Acute Thrombosis of Abdominal Aortic Aneurysm without Acute Limb Ischemia

Acute thrombosis of an abdominal aortic aneurysm (AAA) is a rare and often devastating complication with high morbidity and mortality. In some cases, however, it may be associated with a silent course without signs of acute limb ischemia. The aim of this report is to describe an unusual case of acute thrombosis of AAA without signs of acute limb ischemia. Preoperative anxiety, stress, and phobia for surgery may be factors predisposing to acute thrombosis of an AAA.

Acute Bilateral Lower Extremity Paralysis Secondary to Acute Thrombosis of an Infrarenal Abdominal Aortic Aneurysm

We present the case of a 64-year-old male who presented to the emergency department with bilateral limb ischemia and paralysis for approximately 1 hour. Computed tomographic angiography demonstrated occlusion of the infrarenal aorta beginning just above the patient’s known abdominal aortic aneurysm (AAA) and extending into both common iliac arteries. He was emergently treated via open repair of the AAA with a Gore-Tex tube graft, bilateral common iliac thrombectomies, and bilateral lower extremity four-compartment fasciotomies. Post-operatively, he had monophasic signals in both posterior tibial arteries, neither of which was present before the operation. During recovery, he developed an ileus but otherwise did not have complications. He was discharged to rehabilitation on post-operative day 15.

Endovascular Aneurysm Repair with Balloon Thrombectomy for Acute Thrombosis of Abdominal Aortic Aneurysm

Acute occlusion of abdominal aortic aneurysm (AAA) is a rare complication and is usually treated with surgical reconstruction. We present a case of acute AAA occlusion that was successfully treated by endovascular aneurysm repair (EVAR) with Fogarty balloon thrombectomy. A 77-year-old man with a history of acute myocardial ischemia presented with limb weakness and coldness. Contrast-enhanced computed tomography showed a 42-mm-diameter infrarenal AAA that was completely thrombosed in the distal portion. The proximal neck of the aneurysm was patent, and its shape was suitable for EVAR. Therefore, we performed balloon thrombectomy of the aortoiliac thrombus that was followed by EVAR. EVAR can be a less invasive alternative than traditional treatment for acute occlusion of AAA.

Endovascular Aneurysm Repair of Acute Occlusion of Abdominal Aortic Aneurysm with Intra-Aneurysmal Dissection

BACKGROUND

To report a rare case of acute abdominal aortic aneurysm (AAA) occlusion successfully treated by endovascular aneurysm repair (EVAR).

CASE REPORT

An 89-year-old man complained of severe back pain and weakness in the bilateral lower extremities. Although there were neither acute ischemic signs on the brain computed tomography (CT) nor critical leg ischemia, the patient presented progressing weakness in the bilateral lower extremities and decreased sensation in the perianal and saddle area. Contrast-enhanced CT demonstrated an infrarenal AAA, the formation of an ulcer-like lesion in the aneurysmal wall, and the complete occlusion of distal AAA because of the caudal extension of intramural hematoma. Both common iliac arteries were patent because of the development of collateral vessels. The neurologic symptoms were considered to be caused by the occlusion of lumbar radicular arteries. EVAR seemed anatomically feasible, if the occlusion could be crossed by guidewires from both side of the common femoral artery. Wires easily traversed the occlusion, and the stent graft could be smoothly unwrapped and opened. The patient could recover decent iliac arterial flow. The neurovascular deficits recovered within 4 days after the procedure.

CONCLUSIONS

Although our experience may not be reproduced in all case of AAA occlusion, EVAR warrants consideration to reduce the high mortality rate associated with the classical treatments.

Endovascular Treatment of an Acutely Thrombosed Abdominal Aortic Aneurysm

BACKGROUND

Acute thrombosis of an infrarenal abdominal aortic aneurysm may be a life-threatening condition.

REPORT

We describe a case of acute thrombosis of a 3.5-cm abdominal aortic aneurysm resulting in threatened lower limbs, in a high-risk surgical patient. Emergency stent-graft placement was undertaken using Fluency endoprostheses. The patient remains well at 1-year follow-up.

CONCLUSION

High-risk surgical patients with acutely thrombosed abdominal aortic aneurysms may not be candidates for open surgery. Use of peripheral stent grafts in emergency situation has not been reported in such patients.

Incidental discovery of a chronically thrombosed abdominal aortic aneurysm: case report and literature review

Chronic spontaneously thrombosed abdominal aortic aneurysms (AAAs) are rare. We present a patient with a completely thrombosed abdominal aortic aneurysm found incidentally on imaging for evaluation of unrelated abdominal pain. The patient was asymptomatic with regards to the aneurysm due to extensive collateralization of the intercostal and lumbar arteries to the bilateral hypogastric and internal mammary arteries to the common femoral arteries bilaterally. Follow-up imaging after 10 months showed no aneurysmal change. Further study is needed regarding indications for elective repair, medical therapy, and surveillance modality and schedule for patients with chronically occluded AAAs as these patients are at risk for aneurysm rupture and thrombus propagation.

Chronic complete thrombosis of abdominal aortic aneurysm: An unusual presentation of an unusual complication

Although mural thrombosis frequently accompanies aneurysmal disease, complete thrombosis is distinctly unusual complication of abdominal aortic aneurysm (AAA). A case study of a patient with chronic, asymptomatic complete thrombosis of a large juxtarenal AAA is presented along with a literature review and discussion of the potential secondary complications, mandating aggressive management of this condition. A 67-year-old man with multiple atherogenic risk factors and unattended complaints consistent with a recent episode of a transient right hemispheric ischemic attack was referred to our clinic with a diagnosis of a thrombosed AAA established by computed tomography. Duplex ultrasonography and aortography confirmed the referral diagnosis and also revealed near occlusion of the left internal carotid artery. The patient underwent a two-stage surgery, with preliminary left-sided carotid endarterectomy followed three days later by an aneurysmectomy and aortobifemoral reconstruction. He had an uncomplicated recovery and was discharged home on postoperative day 7, remaining asymptomatic at the 42-month follow-up. Complete thrombosis is an uncommon presentation of AAA and may be clinically silent. It is frequently associated with other manifestations of generalized atherosclerosis. Radical open repair yields durable result and is the preferred treatment modality.

Acute thrombosis of an abdominal aortic aneurysm followed by delayed rupture associated with bacterial infection

Sudden thrombosis of an abdominal aortic aneurysm (AAA) is distinctly rare and is associated with up to 50% mortality. Almost equally rare is infection of a preexisting AAA. We report an extremely unusual case of an AAA that thrombosed leading to acute limb ischemia. This was followed several months later by a delayed rupture of the thrombosed AAA associated with an Escherichia coli infection. We suspect the aortic thrombus was hematogenously seeded by a urinary tract infection. A review of the literature revealed that bacterial infection of a previously thrombosed AAA, leading to a delayed rupture, has not been previously reported.

Acute thrombosis of abdominal aortic aneurysm during cardiac surgery

Aortic thrombosis has been described in the medical literature as a rare and catastrophic complication of abdominal aortic aneurysms. However, it has only been reported once in cardiac surgical settings. We report a unique case of thrombosis of an abdominal aortic aneurysms during the course of cardiac surgery, in a fully anticoagulated patient on cardiopulmonary bypass. Prompt diagnosis and immediate surgical management were critical for a successful outcome.

Acute thrombosis of an abdominal aortic aneurysm: a short report

INTRODUCTION

Sudden thrombosis of an abdominal aortic aneurysm is a rare condition with a high mortality rate.

REPORT

We present a patient with acute neurological deficits in both legs based on a thrombosis of a nine centimetre infrarenal abdominal aortic aneurysm. Successful iliac thrombectomy with aortic tube graft reconstruction was performed.

DISCUSSION

Sudden thrombosis of an abdominal aortic aneurysm is a rare condition, but should be taken into consideration in patients with acute neurological deficits of the lower extremities. Prompt diagnosis and surgical management can lead to a successful outcome. A review of the literature is presented.

Endovascular Treatment of an AcutelyThrombosed AAA

PURPOSE

To report a case of lower extremity ischemia due to acute thrombosis of an abdominal aortic aneurysm (AAA) that was successfully treated with emergent stent-graft placement.

CASE REPORT

A 58-year-old hypertensive man was transferred from an outside hospital with the history of sudden onset of pain, paresis, and purple discoloration of both lower extremities extending up to the umbilicus. Femoral and distal pulses were absent on examination. Contrast-enhanced computed tomography showed a 3.8-cm infrarenal AAA with a large thrombus occluding the bifurcation of the iliac arteries. The patient was treated emergently with an AneuRx stent-graft that excluded the thrombus and the AAA from the circulation, with return of distal pulsation and recovery of ischemic and neurological deficits. At 10-month follow-up, the patient remained asymptomatic.

CONCLUSIONS

Selected cases of acute thrombosis of AAA with favorable anatomy can be treated utilizing endovascular grafts. Extra precaution should be taken to prevent embolization during catheter manipulation and introduction of the large stent-graft devices.

Anesthésie–réanimation d’un patient en ischémie aiguë des membres inférieurs

OBJECTIVES

To appreciate the severity of a patient with acute limb ischaemia, to know how to manage these patients during the perioperative period.

DATA SOURCES

References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: acute limb, ischaemia, prognosis, complications, rhabdomyolysis, hyperkalaemia, compartment syndrome, fasciotomy.

DATA SYNTHESIS

Ischaemia of the lower limbs is a medico-surgical emergency. The ischaemia implies a decrease of cellular energetic stocks and an increase in intracellular calcium. During reperfusion, the calcium paradox is exacerbated and ROS formation produces membrane damage. Tissue oedema and a local and general inflammatory syndrome occur. Clinical symptoms of acute ischaemia include pallor, pulselessness, decrease of temperature and pain. Occurrence of neurological symptoms is a sign of severity. Prognosis of patients relates directly to preexisting collateral circulation, aetiology of the occlusion (thrombosis vs embolus), duration of ischaemia, topography of the occlusion (severity of proximal occlusions as the acute aortic occlusion), and co-morbidity (renal failure, heart failure). The temperature of the ischaemic limb, quality of the downstream circulation, extension of the thrombus, arterial pressure and association to a venous thrombosis are other prognostic factors of lower limb ischaemia. The first treatment to be initiated is high doses of heparin. Once the diagnosis is made, the number of preoperative tests will be as small as possible because of the urgency of revascularization. Arteriography will be performed only when really needed and when its realization will not delay revascularization and will not alter the patient's prognosis. Where general anesthesia is required, the choice of anaesthetic agents will be based on their haemodynamic stability. During severe acute limb ischaemia, monitoring of invasive pressure is recommended, as well as regular dosages of potassium, arterial gases and CPK. Preoperatively in case of severe ischaemia, (proximal occlusion lasting more than 6 hours), preventive treatment, including controlled reperfusion with heparinized serum is indicated. Surveillance and prevention of a rhabdomyolysis and renal failure are imperative. Immediately after reperfusion, a dosage of potassium must be performed; moreover that hyperkalaemia is favoured by acidosis or renal failure. Postoperative haemodialysis is performed in case of hyperkalaemia or renal failure. Occurrence of compartment syndrome has to be checked and fasciotomy must be performed in case of a doubt on the microcirculation integrity.

Rupture of a previously thrombosed thoracoabdominal aneurysm

Spontaneous thrombosis of abdominal aortic aneurysms is rare. A patient with a 12-cm thoracoabdominal aneurysm developed sudden thrombosis of his aneurysm. He was treated with axillobifemoral bypass. He went on to rupture 7 months later. While spontaneous thromboses of abdominal aortic aneurysms have been previously reported, we did not find any reports of a thrombosed thoracoabdominal aneurysm or a subsequent rupture of this type of aneurysm. The literature on thrombosis of aneurysms is reviewed as well as proposed etiologies for thrombosis and subsequent rupture. We believe that resectional therapy may be warranted even in high-risk patients.

Acute thrombosis of abdominal aortic aneurysms--report of two cases and review of the literature

An acutely thrombosed abdominal aortic aneurysm (AAA) is a rare but devastating complication of aortic aneurysms. Incidence in reported series is approximately 0.7-2.8% of surgically managed AAA cases with an associated mortality rate of 50%. To date there have been only 46 cases of acutely occluded AAAs reported in the literature. We present our experience of 2 additional cases of acute AAA thrombosis and discuss the mechanism of thrombosis and management. The size of the aneurysm seems to be a better predictor of rupture than of thrombosis. Strong risk factors for thrombosis are the presence of concomitant iliac artery and cardiac disease. Although this complication is rare, its high mortality rate makes it an important disease to understand, recognize, diagnose, and treat for a successful outcome.